Surgical management of cutaneous sarcoid of the nose
Received: 25 October 2012 / Accepted: 29 November 2012 / Published online: 22 December 2012
Springer-Verlag Berlin Heidelberg 2012
Abstract Cutaneous sarcoid is apparent in around 30 % of
patients with sarcoidosis. Though this particular manifestation
is not life threatening, it can lead to a huge psychological
burden if it is particularly disfiguring or conspicuous. We
report a case of unsightly cutaneous sarcoid that was refrac-
tory to conventional medical treatment but where we were
able to achieve a desirable cosmetic effect with surgery.
Level of Evidence: Level V, therapeutic study.
Sarcoidosis is an enigmatic multi-system disease, characterised by
non-caseating granulomas that can effect virtually any organ. In
over 90 % of patients, sarcoid will manifest as pulmonary, ocular
or skin lesions, but the organ most affected will vary from patient
to patient. Cutaneous lesions occur in around 30 % of patients
with sarcoid and are more common in women than men. Though
cutaneous sarcoid is not life threatening, it can have a huge
psychological impact owing to its unsightly cosmetic affect .
Cutaneous sarcoid is usually managed medically, primarily
with steroids, whether these be topical, injected or oral.
Though they do not provide a panacea and come laden with
a whole host of side effects. Other medical options include
chloroquines, tetracyclines, methotrexate and more recently,
TNF alpha inhibitors. Nevertheless, these bare their own side
effects, and their efficacy is questionable .
We report a case of a 35-year-old lady under our care suffering
refractory cutaneous sarcoid for 5 years (Fig. 1). She was
initially treated with topical steroids but with a poor response.
Triamcinolone 10 mg/ml solution was then injected into
the right nose and left inner canthus, again the result was
poor. Despite trying a further 40 mg/ml injection of triam-
cinolone, a satisfactory cosmetic effect was not achieved.
Treatment escalated to 200 mg BD of hydroxychloroquine,
with minimal improvement. It was felt that systemic ste-
roids, though a popular treatment choice for cutaneous sar-
coid, would not be appropriate for our patient, considering
she was overweight and already had type 2 diabetes.
Conventional treatment of cutaneous sarcoid failed to achieve
an acceptable cosmetic affect for the patient. As a last resort,
surgery was attempted to remove these cutaneous lesions. A
shave excision was performed. This involved the lesions being
shaved flat to the skin using a Dermablade (Personna, Verona,
USA), which is a small flexible hand held blade. The use of a
Dermablade makes it easy to slice a papule close to the skin with
a low risk of forming an indentation. This was done under local
anaesthetic which was injected into the low dermis and subcu-
taneously to avoid excessive swelling of individual lesions. The
lesions were then cauterised. Aftercare consisted of chloram-
phenicol ointment and Dermovate cream (GlaxoSmithKline,
Uxbridge, UK), a particularly potent topical steroid.
All lesions were removed in the same way and chosen for
being the largest and most cosmetically unsightly as there was
little or no concern that matters which could be made any worse.
The likely surgical outcome was discussed with the patient who
was consented for the risk of recurrence and indented scarring.
A surgical approach was chosen as all other treatment thus
so far had failed to make any impact on the size of the lesions
which were so protuberant they were impossible to camou-
flage. Laser treatment may have been considered by others, but
this was not considered to be a feasible option for our patient.
Laser is not provided by the national health service in our area
nor would private laser have been an option in the circum-
stance, particularly considering the lack of good evidence that
this would have been a preferable or more effective treatment.
The cosmetic outcome was exemplary, so much so that
further cutaneous lesions were excised in an identical man-
ner from other areas (Fig. 2). There was no need for skin
grafting, and lesions at 2-year follow-up are yet to reappear.
J. Murphy (*)
Department of Dermatology,
Kettering General Hospital, Kettering, UK
Eur J Plast Surg (2013) 36:385–386